Provider Demographics
NPI:1952762643
Name:BROADERWAY, TIMOTHY S (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:S
Last Name:BROADERWAY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:67439-2328
Mailing Address - Country:US
Mailing Address - Phone:785-472-2193
Mailing Address - Fax:
Practice Address - Street 1:1000 ADAMS ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4208
Practice Address - Country:US
Practice Address - Phone:620-792-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-17189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist